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Dr. Andrew Rynne
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Dr. Andrew Rynne

Family Physician

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What causes severe fatigue, hypersomnia and depression in an elderly woman?

Answered by
Dr.
Dr. Shehzad Topiwala

Endocrinologist

Practicing since :2001

Answered : 1663 Questions

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Posted on Tue, 23 Aug 2016 in Thyroid Problem and Hormonal Problems
Question: My Mom is 93, and up until a few months ago was an amazingly energetic and cognitively alert woman. In the past 6 months, she had a non-bloodborne MRSA cellulitis infection, a fall that caused a rib contusion, and a very mild MI ... all of which she has recovered from. It has been at least 2 months since the last issue, and her LVEF post-MI is still 51%. She is able to tolerate a fair amount of exercise for someone her age (she is able to tolerate machines at cardiac rehab for 15 mins at a time).

The problem is over the past few months she has developed severe fatigue, daytime sleepiness, lack of energy and depression that she says affects her ability to function. Sure, it could be her age, but 6 months ago this was not anywhere near as much of a problem. Hemoglobin is normal, Thyroid is normal (she is on Synthroid), cardiologist says it's not likely to be cardiac related, Serum Glucose is 78 (normal), Serum Electrolytes (Sodium, Potassium, Chloride) all normal. Kidney and Liver Enzymes all normal.

My question is this. Her last endocrinological blood workup in May indicated an Intact PTH of 82 pg/ml with a Serum Calcium of 9.3 mg/dl. The PTH is elevated. When I read the symptoms of Hyperparathyroidism, I see many of her complaints. Given the elevated PTH, but a normal Serum Calcium ... could the elevated PTH be the cause of her recent complaints of fatigue, depression and lack of energy?
doctor
Answered by Dr. Shehzad Topiwala 48 minutes later
Brief Answer:
Vitamin D deficiency

Detailed Answer:
Although you are correct that a high PTH can cause symptoms like the one she is experiencing, that situation typically reflects a different problem called Primary Hyperparathyroidism.
It is important to evaluate for the cause of the raised PTH. One of the most common causes for this is vitamin D deficiency. So I recommend the following blood tests:

Fasting Ionized Calcium
Phosphorus
Magnesium
25 hydroxy Vitamin D levels (ideal range 40 to 60 ng/ml = 100 to 150 nmol/liter)

Treating a low vitamin D often lowers and normalizes the PTH level n the blood.
It is possible some or all of her symptoms may improve depending on whether she has a low level and if so whether it is severely low or not. Treatment will likely cause greater improvement if a severe deficiency is treated versus a mild one may not cause her to feel much different.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Shehzad Topiwala 21 minutes later
Thank you. We do not have a fasting ionized calcium or a Phosphorus. But recent results:

VITAMIN D,25-OH,TOTAL,IA was 37 ng/ml and 32 ng/ml about 2 months prior.
Recent Magnesium was 1.7 mg/dl
doctor
Answered by Dr. Shehzad Topiwala 25 hours later
Brief Answer:
Follow up

Detailed Answer:
I see. The vitamin D levels are sufficient. It is unlikely they would have dropped in two months although with these 'calciotropic' hormone tests it is ideal if they are all measured around the same time, often in the same sample.
So consider testing the other two things I mentioned, with a repeat PTH check on the same blood sample at a reliable laboratory because the collection techniques are important
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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